Provider Demographics
NPI:1043394497
Name:FORT WORTH FOOT CLINIC
Entity Type:Organization
Organization Name:FORT WORTH FOOT CLINIC
Other - Org Name:FORT WORTH MED EX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANNA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:817-923-1953
Mailing Address - Street 1:4759 B SOUTH FREEWAY
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115
Mailing Address - Country:US
Mailing Address - Phone:817-923-1953
Mailing Address - Fax:817-923-9615
Practice Address - Street 1:4759 B SOUTH FREEWAY
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115
Practice Address - Country:US
Practice Address - Phone:817-923-1953
Practice Address - Fax:817-923-9615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies